Healthcare Provider Details

I. General information

NPI: 1346919990
Provider Name (Legal Business Name): KRISTEN GRACE EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 SUGAR CAMP BRANCH
LENORE WV
25676
US

IV. Provider business mailing address

140 SUGAR CAMP BRANCH
LENORE WV
25676
US

V. Phone/Fax

Practice location:
  • Phone: 304-475-4703
  • Fax:
Mailing address:
  • Phone: 304-475-4703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: